Healthcare Provider Details

I. General information

NPI: 1588376040
Provider Name (Legal Business Name): LETICIA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 E WASHINGTON BLVD
LOS ANGELES CA
90021-3068
US

IV. Provider business mailing address

1005 E WASHINGTON BLVD
LOS ANGELES CA
90021-3068
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: